Written by Hannah Harp
Spoon Feed
Patients with both ADHD (attention deficit/hyperactivity disorder) and DMDD (disruptive mood dysregulation disorder) more frequently utilize inpatient or ED services and are more likely to be prescribed antipsychotics and mood stabilizers, though many don’t have optimized ADHD medications or psychotherapy.
Build up, then build out
A sizable subset of patients with ADHD are also diagnosed with DMDD, i.e. persistent irritability with recurrent angry outbursts, which is associated with more severe ADHD symptoms and higher rates of depression, substance use, and suicide. Importantly, CNS stimulants (at optimized dosages) are effective for reducing irritability and anger in kids with ADHD/DMDD without having the hefty side effect profile of antipsychotics and mood stabilizers.
This retrospective cohort study analyzed national treatment trends for youth with ADHD and DMDD using data from 656,018 patients. Compared to ADHD alone, ADHD + DMDD patients had higher rates of psychiatric comorbidities, inpatient or emergency service utilization, and psychotropic prescriptions, including CNS stimulants, alpha-2 agonists, mood stabilizers, antipsychotics, and antidepressants. Use of antipsychotics and mood stabilizers increased most significantly (OR 13.16 and 3.76-13.42, respectively). Only 11% had their ADHD medication optimized before mood stabilizer/antipsychotic initiation; only 25% had a billing code for psychotherapy before non-ADHD medication use. Additionally, Hispanic and non-White children were less likely to receive therapy services. The increased non-stimulant prescriptions for patients with ADHD + DMDD highlights the need for optimized ADHD treatment sequencing. Since these data were pulled from a research database populated from EMR and billing sources, it’s difficult to know what information has been lost because of coding errors or non-billable services.
How will this change my practice?
I can definitely see how my own practice reflects what is described in the paper – I treat uncomplicated ADHD myself, but once I suspect DMDD or ODD, I usually refer to a specialist and psychotherapy. Now, I’ll focus on optimizing stimulant medications during the long wait for a psychiatry appointment.
Source
Pediatric Attention-Deficit/Hyperactivity Disorder and Disruptive Mood Dysregulation Disorder: Analyzing National Treatment Trends. J Pediatr. 2025 Apr;279:114471. doi: 10.1016/j.jpeds.2025.114471. Epub 2025 Jan 17. PMID: 39828054
